When it comes to patient engagement design, how do we know where to begin? Stacey Chang compares the task to zebras in the African savanna, whose stripes have a distinct utility. When in a herd, the overlap of stripes creates a confusing pattern, making it difficult for predators to distinguish between one zebra and another. When that herd moves, the pattern becomes even more confusing, and establishing a singular starting point for a predator becomes practically impossible.

The similarity, of course, is that the herd is our health care system. We’re obviously in pursuit of a different goal — a better patient outcome, not a zebra to eat. But the confusing and complex set of people, interactions, and tools makes it hard to focus, prioritize, and act. Finding a singular starting point often feels impossible.

If you accept for a moment that the patient has the greatest vested interest in getting healthy and staying healthy, and potentially the greatest influence on that gain, then the notion of patient engagement changes meaningfully.”

“That confusion also masks a fundamental truth, which is: one member of this herd is unique. There is one person in the system who has a greater interest in a positive patient outcome than anybody else, and that’s the patient. If you accept for a moment that the patient has the greatest vested interest in getting healthy and staying healthy, and potentially the greatest influence on that gain, then the notion of patient engagement changes meaningfully,” says Chang.

Patient engagement, then, is not trying to get patients to act in spite of their motivations, or in spite of a set of behaviors that they’re not inclined to do — it’s about understanding that human motivation more deeply, and then channeling it so that we can encourage and enable patients to act in beneficial ways.

Chang offers two examples from outside of health care:

The Toyota Prius has found huge success as the automobile that established the global market for hybrid, electric gasoline vehicles. Their success is deserved, Chang says, because Toyota, before anyone else, recognized that there was a section of the car-buying public that would pay more to fulfill an obligation toward environmental responsibility. Perhaps more importantly, what Toyota did was develop a set of technologies that can deliver a car that gets 54 miles to the gallon.

But, says Chang, there’s a dirty little truth that doesn’t get talked about very often: that much of the Toyota Prius’s efficiency gain has nothing to do with its underlying technology. Somewhere between a third and a half of the efficiency gain actually comes from the behavior change its drivers willingly adopt. How does Toyota do that? By tapping into the eco-friendly motivation of the buyer, and engaging them in a game that happens inside the car through the interactive infographic on the dashboard. By showing how energy is utilized, generated, and traded between the engine, the battery, and the electric motor, it becomes a game of optimization for the driver. “If you ask any Prius owner, they’ll tell you how much time they’ve spent modifying their behavior and driving habits to maximize the output, which just reinforces their original motivation for buying this car,” Chang says.

It doesn’t matter if it came from the technology or if it came from the behavior change that the drivers adopt. Customers don’t distinguish between the two. They just give the car company credit for having created this remarkable product that fulfills their eco-friendly aspirations.”

It turns out that you don’t even need the level of technical detail in the Toyota model — Chang notes that Ford’s version is essentially just a digital plant that grows and thrives “when you drive like your grandmother and then withers and dies if you drive like Mario Andretti. But it doesn’t matter — this is sufficient to create the behavior change.”

The sheer brilliance of this, says Chang, is that the car manufacturers get all of the credit for all of the efficiency gain. “It doesn’t matter if it came from the technology or if it came from the behavior change that the drivers adopt. Customers don’t distinguish between the two. They just give the car company credit for having created this remarkable product that fulfills their eco-friendly aspirations.”

Another example is when airlines introduced the interactive seat map you can engage with when purchasing a ticket. Oftentimes, people will happily pay to move into a seat that’s more valuable to them. The seat map is fast, it’s more transparent, and it grants passengers more control over their experience. At the same time, the airline generates more revenue, they manage the passenger load better, and it takes less staff on their side to see this happen. When these offers first launched, the airlines were credited with prioritizing the customer, but in truth, the airlines were driving most of the benefit from the offer.

Several themes emerge from these two examples. A good engagement strategy:

Reinforces the motivations of the customer,

Grants control over parts of the process to the customer,

Embeds engagement in the natural flow of the experience,

Aligns the system’s incentives with the customer’s motivations, and

Is self-learning — the data you generate helps define and design the next iteration better.

There are notable examples in health care as well, such as Hogeweyk, a new care model in the Netherlands for seniors with dementia. Hogeweyk is a village — an approximation of where the seniors used to live — where they’re given a choice of housing, and on a daily basis have the freedom to choose if they want to go to the grocery store, the beauty parlor, or watch a movie — whatever they like. But it’s all done in the confines of a gated and secure community. Importantly, says Chang, the caregivers play the role of community members by interacting in nonconfrontational ways in daily exchanges. In this way, the caregivers are more like companions than gatekeepers. “The results are remarkable,” says Chang. “The patients are active, they interact more with each other, they need fewer medications, all at costs that are quite similar to traditional nursing homes. The caregivers report greater autonomy and greater satisfaction in their work, because they find themselves not at odds with the patients they’re caring for.”

Patient engagement, then, is not trying to get patients to act in spite of their motivations, or in spite of a set of behaviors that they’re not inclined to do — it’s about understanding that human motivation more deeply, and then channeling it so that we can encourage and enable patients to act in beneficial ways.”

Another example is from Kaiser Permanente. For mothers in a hospital recovering from childbirth, in addition to recovery, a number of tasks have to happen before discharge. These tasks are seemingly unrelated and can create anxiety for the mother, because she doesn’t know when they have to be completed or in what order. Similarly, the nurses caring for the mothers and newborns have to keep track of those tasks, and in shift changes, things can get lost. “Kaiser’s solution to this was surprisingly low-tech,” says Chang. It was a bulletin board called Your Journey Home, put in the delivery room for the mother. On the board are tags including tasks that can be hung on hooks and moved around, displaying what tasks need to be completed and when before the mother and baby can go home. When a task is completed, the tag is flipped over to display a check mark. This serves as a physical reminder of the continuum of care, in that discussions about the patient’s care or tasks take place in front of the board, allowing the mother to be part of the conversation and fill in potential gaps.

These examples illustrate an important aspect of designing care for better patient engagement: knowing the customer’s — or the patient’s — motivations is crucial for understanding how they align with a health system’s priorities. When you understand both, you can design a solution that benefits both.

“What I hope this reveals is that we are in alignment more than we acknowledge across the system,” adds Chang.

Design Institute for Health, The University of Texas at Austin

Stacey Chang serves as the Executive Director of the Design Institute for Health, a collaboration between the Dell Medical School and the College of Fine Arts at the University of Texas at Austin. Learn more about Stacey Chang...

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keith

Julia Gilstein

Online Editor, NEJM Catalyst

Hi Keith,
Thanks for letting us know. Refresh the page and try again. Or you can watch the video here: https://youtu.be/lP4dKILPGp8

May 31, 2017 at 11:44 am

Marianne Roncoli

I just came home from the Mayo Clinic, the best health care system in America. People go to a lot of trouble to get to this place. Patients are engaged before they even come. They feel like they create the Care they need and marvel at how well the place attends to the very needs people have. The Clinic has a saying, "put the patient first." That's what they do, but the patient feels like they have organized their own care. I live in NYC, home to reportedly a cornucopia of world class medical centers. Truth be told they don't put patients first or attend to the 6 points identified above.

but marvel at how integrated the care is

June 01, 2017 at 12:46 pm

Amanda S.

Marianne- I couldn't agree with you more!! I was lucky enough to have been a patient a few years ago at the Mayo Clinic in Arizona (which I had no knowledge that any others existed other than in Rochester) but when I went, oh my goodness! I can't put into words better than you can, to describe how amazing my experience was. (But I'll try! lol)
I come from Southern California where we too have some of "the best" / top rated hospitals and facilities in the country, or so they claim, and yet - even visiting them prior to my visits to Mayo and then my appts after- these top notch California hospitals don't hold a candle to the quality care across every board and standard of excellence. Mayo has the most unbelievable system set up, from when you get there to receiving an itinerary to speaking with a nurse and having vitals quickly taken. Then being seen by a doctor- all which allowed me ample time (and then some to ask more than enough questions). I mention this because every step along the way each employee and team member communicated well and had good rapport with one another- you could see it, and as a patient you felt that any and all of your concerns were heard, notated, discussed and validated. The reason the patient knows this to be true, is not just that the doctor receives your concerns verbally in the appt, but there's a real-time Mayo Clinic app (the MOST efficient health software I've used and this was nearly 4 years ago) so you can read the doctor's chart notes and everything. They leave it totally transparent.

I would like to comment that I love this post too, sorry for the Mayo Clinic tangent. But as a long time patient who's experienced such extremes - in facilities and hospital career, I feel like Mayo Clinic has a very good patient engagement protocol in place and that other organizations should follow.